Copays Break Law

By Mary K. Reinhart
The Arizona Republic, August 25, 2011

The three-judge panel of the 9th U.S. Circuit Court of Appeals said federal health officials failed to show how the copays, imposed in November after a seven-year court battle, served any purpose besides cutting the state’s Medicaid budget.

Raising copayments for more than 200,000 of Arizona’s poorest residents and making them mandatory, the judges said, helped balance the state budget but didn’t meet that federal standard.

“The administrative record reveals that the purpose of Arizona’s waiver application was to save money,” wrote Judge Richard Paez. “There is little, if any, evidence that the secretary considered the factors (federal law) requires her to consider before granting Arizona’s waiver. Thus, the secretary’s decision was arbitrary and capricious.”

The copays, which range from $4 to $30, were first approved by lawmakers in 2003 and were in place for about four months before a class-action suit was filed and a federal judge put them on hold. That stay was lifted in November by a separate appeals-court panel, which upheld a March 2010 ruling by U.S. District Judge Earl Carroll.

Since November, childless adults covered under the Arizona Health Care Cost Containment System, the state’s Medicaid program, and those who spend down their savings to become AHCCCS eligible can be turned down for medical care and medications if they can’t afford the copayment.

http://www.azcentral.com/arizonarepublic/local/articles/2011/08/25/20110825ahcccs-copays-break-law-ruling.html

These are patients with incomes below the federal poverty level. Requiring a co-payment before access to care is permitted causes many of these individuals to go without medical care. It is appropriate that the Court of Appeals panel ruled that the HHS Secretary was “arbitrary and capricious” in approving the waiver that authorized the imposition of co-payments.

What is the purpose of co-payments? Some say that it is to prevent people from obtaining medical care that they don’t really need. Really? If a person has decided that she should see a physician, and she can afford the co-payment, would that really stop her from obtaining care? Highly unlikely.

Then is the co-payment for the purpose of raising revenues to help fund health care? The administrative hassle of processing co-payments offsets much of the gain that the co-payment revenues would bring.

Yet co-payments for low-income individuals clearly impair access to beneficial health care services. Thus co-payments provide little good and cause real harm.

Deductibles and coinsurance are another matter. For the very wealthy, they have no impact on health care access. But for middle-income individuals they are enough of a financial burden that they do cause patients to forego beneficial health care – obviously an undesirable policy.

How effective are deductibles and coinsurance in raising revenues to pay for health care? About 80 percent of health care is consumed by individuals who are no longer sensitive to the costs because they have already met their cost-sharing requirements. Thus they play a negligible role in funding our total national health expenditures.

The primary role that cost sharing plays in reducing health care spending is to prevent individuals from receiving care that they should have. (The value of reductions in non-essential services that result from cost sharing has been overstated since consultations with reassurance are still very beneficial health care services.)

So how much does foregoing beneficial care really save? Estimates based on the RAND HIE have suggested that the amount saved is about 30 percent. But 30 percent of what? It is 30 percent of the care consumed by healthy workers and their young healthy families, most of whom do not have major health expenses. Once you factor in the entire population, including all major medical disorders, the percentage of care that would be avoided is negligible.

Many other countries that spend far less while covering everyone do not have deductibles, co-payments, nor coinsurance. They have found them to be unnecessary in controlling costs. They are an insignificant revenue source, and they can cause harm, especially in vulnerable groups such as Arizona’s adult Medicaid population, and now in middle-income Americans who must live with the new standard of under-insurance.

It didn’t have to be this way.

By Larry Levitt and Gary Claxton
Kaiser Family Foundation, August 24, 2011

A recent draft regulation issued by the Treasury Department describes who is eligible for premium tax credits to help them afford coverage offered through health insurance exchanges beginning in 2014. The approach that the regulation proposes for measuring the affordability of employer coverage could have significant financial consequences for a modest number of lower- and middle-income families.

Starting in 2014, the health reform law generally requires people to have health insurance and provides tax credits to help them afford it. Those who are offered health insurance through a job, however, are expected to take that coverage and generally are not eligible for premium tax credits. This includes both the worker and any family members who are eligible to enroll in the job-based coverage. There is an exception to this rule, though: if people are offered coverage by an employer that has patient cost-sharing above a certain level or is unaffordable, they are permitted to forgo the employer plan and apply for a tax credit that can be used for coverage in an exchange. Job-based coverage is considered unaffordable if the amount of the out-of-pocket premium for the employer coverage exceeds 9.5% of that person’s income.

While it’s clear how this applies to a single worker without any dependents, determining a family’s eligibility for premium tax credits is far less clear in the law. One way would be to look at what the family would have to pay for coverage based on its size and compare that to its income. A second way, which the Treasury Department has proposed, would judge affordability for the entire family based solely on whether the employee’s contribution for single coverage would exceed 9.5% of family income, regardless how much it would cost the entire family to enroll in job-based coverage. A third hybrid approach is also possible: affordability for the worker could be determined based on the required contribution for single coverage while affordability for the remaining family members would be based on the required contribution for family coverage.

What would this mean for families? We estimated the effect based on coverage in 2008 using demographic and insurance data from the Medical Expenditure Panel Survey and employee premium contribution information from the Kaiser/HRET Employer Health Benefits Survey. The analysis – which assumes no behavior changes by employers in response to the health reform law – suggests that there are about 3.9 million non-working dependents in families (technically, “health insurance units”) in which the worker has access to affordable employer-sponsored coverage but the family does not. Under the draft regulation, these family members would be excluded from getting federal tax credits to help them buy coverage in health insurance exchanges. On average they’d have to pay 14% of their income to opt into the employer coverage, substantially more than what they would pay in an exchange.

In the draft regulation, the Treasury Department indicated that it expects to exempt these family members from the requirement to buy insurance, so they won’t be penalized if they choose to forego coverage. Some of these families would probably still decide to enroll in their employer coverage even though they would have to pay a large percentage of income for it; that would likely be the case even if they were permitted to buy subsidized insurance in an exchange. People value insurance, and they particularly value employer-provided benefits. But, some of these family members would undoubtedly remain uninsured.

http://healthreform.kff.org/notes-on-health-insurance-and-reform/2011/august/measuring-the-affordability-of-employer-health-coverage.aspx

Comment: 

By Don McCanne, MD

Although this policy failure of the Affordable Care Act (ACA) was touched on briefly in a recent message, it is elaborated on here because of its great importance to families.

To avoid being assessed a penalty for being uninsured, most employees will be required to obtain their health insurance through their employment. They will not be allowed the option of obtaining coverage through the state insurance exchanges and will have to forego the tax credits available for exchange plans, unless their premium is unaffordable (over 9.5% of income).

But what about their families? The Treasury Department (IRS) has tentatively ruled that ACA prohibits them from using the insurance premium for the family to determine whether it meets the threshold of affordability. Only the individual employee’s premium can be used. Even though the premium for family members may be unaffordable, they are not allowed the option of using tax credits to purchase plans in the exchanges.

What are they to do? The IRS agrees that these family premiums are unaffordable so they are ruling that the family members have a right to remain uninsured without having to pay the penalty required by the individual mandate. Our government in action – protecting the right to remain uninsured!

This is not a Catch 22, but rather a Catch 4,000,000 since it is estimated that close to four million dependents will fall into this trap in which the worker has access to “affordable” employer-sponsored coverage but the family members do not. This will impact most heavily middle-income families since those with low incomes may be eligible for Medicaid, and those with very high incomes will likely be able to afford family coverage.

What happened to the American dream? The dream wherein hard working, middle income families could be assured of shelter, food, education, and health care? It seems that all they can be guaranteed today is the right to participate in a tea party, that is if they bring their own tea.

Measuring the Affordability of Employer Health Coverage

By Larry Levitt and Gary Claxton
Kaiser Family Foundation, August 24, 2011

A recent draft regulation issued by the Treasury Department describes who is eligible for premium tax credits to help them afford coverage offered through health insurance exchanges beginning in 2014. The approach that the regulation proposes for measuring the affordability of employer coverage could have significant financial consequences for a modest number of lower- and middle-income families.

Starting in 2014, the health reform law generally requires people to have health insurance and provides tax credits to help them afford it. Those who are offered health insurance through a job, however, are expected to take that coverage and generally are not eligible for premium tax credits. This includes both the worker and any family members who are eligible to enroll in the job-based coverage. There is an exception to this rule, though: if people are offered coverage by an employer that has patient cost-sharing above a certain level or is unaffordable, they are permitted to forgo the employer plan and apply for a tax credit that can be used for coverage in an exchange. Job-based coverage is considered unaffordable if the amount of the out-of-pocket premium for the employer coverage exceeds 9.5% of that person’s income.

While it’s clear how this applies to a single worker without any dependents, determining a family’s eligibility for premium tax credits is far less clear in the law. One way would be to look at what the family would have to pay for coverage based on its size and compare that to its income. A second way, which the Treasury Department has proposed, would judge affordability for the entire family based solely on whether the employee’s contribution for single coverage would exceed 9.5% of family income, regardless how much it would cost the entire family to enroll in job-based coverage. A third hybrid approach is also possible: affordability for the worker could be determined based on the required contribution for single coverage while affordability for the remaining family members would be based on the required contribution for family coverage.

What would this mean for families? We estimated the effect based on coverage in 2008 using demographic and insurance data from the Medical Expenditure Panel Survey and employee premium contribution information from the Kaiser/HRET Employer Health Benefits Survey. The analysis – which assumes no behavior changes by employers in response to the health reform law – suggests that there are about 3.9 million non-working dependents in families (technically, “health insurance units”) in which the worker has access to affordable employer-sponsored coverage but the family does not. Under the draft regulation, these family members would be excluded from getting federal tax credits to help them buy coverage in health insurance exchanges. On average they’d have to pay 14% of their income to opt into the employer coverage, substantially more than what they would pay in an exchange.

In the draft regulation, the Treasury Department indicated that it expects to exempt these family members from the requirement to buy insurance, so they won’t be penalized if they choose to forego coverage. Some of these families would probably still decide to enroll in their employer coverage even though they would have to pay a large percentage of income for it; that would likely be the case even if they were permitted to buy subsidized insurance in an exchange. People value insurance, and they particularly value employer-provided benefits. But, some of these family members would undoubtedly remain uninsured.

http://healthreform.kff.org/notes-on-health-insurance-and-reform/2011/august/measuring-the-affordability-of-employer-health-coverage.aspx

Although this policy failure of the Affordable Care Act (ACA) was touched on briefly in a recent message, it is elaborated on here because of its great importance to families.

To avoid being assessed a penalty for being uninsured, most employees will be required to obtain their health insurance through their employment. They will not be allowed the option of obtaining coverage through the state insurance exchanges and will have to forego the tax credits available for exchange plans, unless their premium is unaffordable (over 9.5% of income).

But what about their families? The Treasury Department (IRS) has tentatively ruled that ACA prohibits them from using the insurance premium for the family to determine whether it meets the threshold of affordability. Only the individual employee’s premium can be used. Even though the premium for family members may be unaffordable, they are not allowed the option of using tax credits to purchase plans in the exchanges.

What are they to do? The IRS agrees that these family premiums are unaffordable so they are ruling that the family members have a right to remain uninsured without having to pay the penalty required by the individual mandate. Our government in action – protecting the right to remain uninsured!

This is not a Catch 22, but rather a Catch 4,000,000 since it is estimated that close to four million dependents will fall into this trap in which the worker has access to “affordable” employer-sponsored coverage but the family members do not. This will impact most heavily middle-income families since those with low incomes may be eligible for Medicaid, and those with very high incomes will likely be able to afford family coverage.

What happened to the American dream? The dream wherein hard working, middle income families could be assured of shelter, food, education, and health care? It seems that all they can be guaranteed today is the right to participate in a tea party, that is if they bring their own tea.

By Michelle M. Doty, Sara R. Collins, Ruth Robertson, and Tracy Garber
The Commonwealth Fund, August 2011

Chronically high unemployment has left millions of Americans without health insurance, which disappeared along with their wages and other job benefits. Although continuing health coverage through COBRA is an option for some workers, the often prohibitively high cost means that relatively few elect to purchase it. When fully implemented in 2014, the Affordable Care Act will dramatically increase health insurance options for people who lose their jobs. Even so, gaps in coverage will remain a risk for many workers who become unemployed or are transitioning to a new job. To help bridge coverage gaps until 2014, policymakers should consider reestablishing the COBRA premium subsidies that helped millions of people who lost their jobs in 2008–2010.

http://www.commonwealthfund.org/~/media/Files/Publications/Issue%20Brief/2011/Aug/1540_Doty_when_unemployed_means_uninsured_COBRA_reform%20brief.pdf

And…

Maintaining Coverage, Affordability, and Shared Responsibility When Income and Employment Change

By Pamela Farley Short, Katherine Swartz, Namrata Uberoi, and Deborah Graefe
The Commonwealth Fund, May 2011

The Affordable Care Act builds on existing sources of public and private health insurance, while creating new health insurance exchanges and subsidies. A potential disadvantage of preserving many sources of health insurance is the likelihood of abrupt changes in coverage or financial responsibility when individual circumstances change. This brief describes four policy challenges related to such changes: adjusting premium and cost-sharing subsidies when incomes change; coordinating eligibility for premium credits, Medicaid, and the Children’s Health Insurance Program; encouraging and facilitating continuous coverage; and minimizing transitions between individual and small-business exchanges. Policy recommendations to reduce uncertainty, simplify coverage decisions, and minimize insurance transitions include extending coverage to the open enrollment period at the end of the year, generous treatment of income gains in correcting premium tax credits, and unifying the small-business and individual exchanges.

http://www.commonwealthfund.org/~/media/Files/Publications/Issue%20Brief/2011/May/1503_Short_maintaining_coverage_affordability_reform_brief.pdf

Comment: 

By Don McCanne, MD

How many individuals continue in the same employment for their entire careers, with the same employer-sponsored health plan, with the same network of health care providers, with the same…? Well, we can stop there. Nobody does.

Generally, individuals in well-paid occupations in high demand who change their employment may face some transitional issues with health plans and provider networks, but usually they fare quite well, even if annoyed at the prospect of perhaps having to change their primary health care professionals, or whatever.

But what about low and moderate income individuals? Job instability is the norm. Income levels can fluctuate considerably. Periods of prolonged unemployment are now more common, and, based on economic projections, will likely persist into the foreseeable future.

The Affordable Care Act has so many slippery variables that it is almost impossible to predict what one’s coverage will be beyond a couple of years, if that. Eligibility can change sometimes on a monthly basis (exchange plans) or yearly basis (Medicaid) for various programs including employer-sponsored plans, Medicaid, CHIP, state exchange plans, or state Basic Health Plans. Eligibility for tax credits for premiums in the exchange plans and for cost sharing reductions can be very unstable because of fluctuations in income. Even waiver of the penalty for failure to purchase private insurance can trigger in or out quite abruptly.

The newest Commonwealth Fund report addresses specifically the problem of coverage during intervals of unemployment. COBRA plans allow newly unemployed workers to continue with coverage under their former employer-sponsored plans but with the out-of-work former employees having to pay the full premiums. COBRA plans have had an unacceptably low participation simply because a person out of work cannot pay the premiums.

To address the problem of unaffordable COBRA premiums that became even more prevalent during the Great Recession, the American Recovery and Reinvestment Act (ARRA) authorized premium subsidies for the purchase of COBRA plans, but that program has expired.

To provide coverage during transitions of unemployment in the future, the authors of this report suggest that the subsidies be permanently resuscitated. The problem with this approach is, even with these temporary subsidies, the COBRA take-up rate was still well less than half of eligible former employees. Policies that don’t work shouldn’t take precedence over policies that do.

You can apply all of the patches that you can devise to the leaking ship of the Affordable Care Act, but it is still going to leak. As more patches are applied, it is further weighted down with greater expenses and with even more administrative burdens – enough to sink any ship.

You want something that floats? Try enrolling everyone at birth, permanently. The solid ship of Medicare for All would have no leaks to patch.

When Unemployed Means Uninsured: The Toll of Job Loss on Health Coverage, and How the Affordable Care Act Will Help

By Michelle M. Doty, Sara R. Collins, Ruth Robertson, and Tracy Garber
The Commonwealth Fund, August 2011

Chronically high unemployment has left millions of Americans without health insurance, which disappeared along with their wages and other job benefits. Although continuing health coverage through COBRA is an option for some workers, the often prohibitively high cost means that relatively few elect to purchase it. When fully implemented in 2014, the Affordable Care Act will dramatically increase health insurance options for people who lose their jobs. Even so, gaps in coverage will remain a risk for many workers who become unemployed or are transitioning to a new job. To help bridge coverage gaps until 2014, policymakers should consider reestablishing the COBRA premium subsidies that helped millions of people who lost their jobs in 2008–2010.

http://www.commonwealthfund.org/~/media/Files/Publications/Issue%20Brief/2011/Aug/1540_Doty_when_unemployed_means_uninsured_COBRA_reform%20brief.pdf

And…

Maintaining Coverage, Affordability, and Shared Responsibility When Income and Employment Change

By Pamela Farley Short, Katherine Swartz, Namrata Uberoi, and Deborah Graefe
The Commonwealth Fund, May 2011

The Affordable Care Act builds on existing sources of public and private health insurance, while creating new health insurance exchanges and subsidies. A potential disadvantage of preserving many sources of health insurance is the likelihood of abrupt changes in coverage or financial responsibility when individual circumstances change. This brief describes four policy challenges related to such changes: adjusting premium and cost-sharing subsidies when incomes change; coordinating eligibility for premium credits, Medicaid, and the Children’s Health Insurance Program; encouraging and facilitating continuous coverage; and minimizing transitions between individual and small-business exchanges. Policy recommendations to reduce uncertainty, simplify coverage decisions, and minimize insurance transitions include extending coverage to the open enrollment period at the end of the year, generous treatment of income gains in correcting premium tax credits, and unifying the small-business and individual exchanges.

http://www.commonwealthfund.org/~/media/Files/Publications/Issue%20Brief/2011/May/1503_Short_maintaining_coverage_affordability_reform_brief.pdf

How many individuals continue in the same employment for their entire careers, with the same employer-sponsored health plan, with the same network of health care providers, with the same…? Well, we can stop there. Nobody does.

Generally, individuals in well-paid occupations in high demand who change their employment may face some transitional issues with health plans and provider networks, but usually they fare quite well, even if annoyed at the prospect of perhaps having to change their primary health care professionals, or whatever.

But what about low and moderate income individuals? Job instability is the norm. Income levels can fluctuate considerably. Periods of prolonged unemployment are now more common, and, based on economic projections, will likely persist into the foreseeable future.

The Affordable Care Act has so many slippery variables that it is almost impossible to predict what one’s coverage will be beyond a couple of years, if that. Eligibility can change sometimes on a monthly basis (exchange plans) or yearly basis (Medicaid) for various programs including employer-sponsored plans, Medicaid, CHIP, state exchange plans, or state Basic Health Plans. Eligibility for tax credits for premiums in the exchange plans and for cost sharing reductions can be very unstable because of fluctuations in income. Even waiver of the penalty for failure to purchase private insurance can trigger in or out quite abruptly.

The newest Commonwealth Fund report addresses specifically the problem of coverage during intervals of unemployment. COBRA plans allow newly unemployed workers to continue with coverage under their former employer-sponsored plans but with the out-of-work former employees having to pay the full premiums. COBRA plans have had an unacceptably low participation simply because a person out of work cannot pay the premiums.

To address the problem of unaffordable COBRA premiums that became even more prevalent during the Great Recession, the American Recovery and Reinvestment Act (ARRA) authorized premium subsidies for the purchase of COBRA plans, but that program has expired.

To provide coverage during transitions of unemployment in the future, the authors of this report suggest that the subsidies be permanently resuscitated. The problem with this approach is, even with these temporary subsidies, the COBRA take-up rate was still well less than half of eligible former employees. Policies that don’t work shouldn’t take precedence over policies that do.

You can apply all of the patches that you can devise to the leaking ship of the Affordable Care Act, but it is still going to leak. As more patches are applied, it is further weighted down with greater expenses and with even more administrative burdens – enough to sink any ship.

You want something that floats? Try enrolling everyone at birth, permanently. The solid ship of Medicare for All would have no leaks to patch.

By Carl van Walraven MD MSc, Alison Jennings MA, Monica Taljaard PhD, Irfan Dhalla MD MSc, Shane English MD, Sunita Mulpuru MD, Saul Blecker MD, Alan J. Forster MD MSc
CMAJ (Canadian Medical Association), August 22, 2011

Urgent, unplanned hospital readmissions are increasingly being used to measure institutional or regional quality of care. The public reporting of readmissions and their use in considerations for funding suggest a belief that readmissions indicate the quality of care provided by particular institutions. However, urgent readmissions are an informative metric only if we know what proportion of them are avoidable. If they are rarely avoidable, they would be a poor gauge of the quality of patient care.

Current estimates of the proportion of urgent readmissions that are avoidable are unreliable. In a systematic review of 34 studies that reviewed how many readmissions were avoidable, 3 of the studies relied solely on combinations of administrative diagnostic codes, and most used undefined or subjective criteria. In addition, most of the studies were conducted at a single centre and used only one reviewer. The proportion of readmissions deemed avoidable varied widely, from 5.1%6 to 78.9%,7 which reflected in part the lack of standardized and reliable methods to identify avoidable readmissions.

We conducted a multicentre prospective cohort study to elicit judgments from multiple practising physicians who used standard implicit review methods to determine whether urgent re admissions were potentially avoidable. We analyzed these judgments using a latent class analysis. We also measured the proportion of readmissions deemed avoidable and compared hospital-specific proportions of all-cause and avoidable readmissions.

Conclusion

Urgent readmissions deemed potentially avoidable were relatively uncommon, comprising less than 20% of all urgent readmissions following hospital discharge. Hospital-specific proportions of patients who were readmitted were not related to proportions of those whose readmissions were deemed avoidable.

Given the variety of causes and circumstances of the potentially avoidable readmissions in our study, interventions to decrease the risk of readmission need to be multifactorial in nature and malleable to be appropriately tailored for each situation.

Our study has important implications for research into the quality of hospital care. First, determining whether urgent readmissions were avoidable is a subjective judgment that requires detailed patient data, multiple reviewers and an analysis that accounts for differing reviewer accuracy when collating judgments. Such judgments cannot be determined accurately on the basis of administrative data alone, given the infinite combinations of patient, hospital, treatment and post-discharge factors that can influence urgent readmissions. Second, we found no association between hospital-specific proportions of all-cause and avoidable readmissions. Therefore, urgent readmissions should be used with caution to gauge the quality of hospital care.

http://www.cmaj.ca/content/early/2011/08/22/cmaj.110400.full.pdf+html

Comment: 

By Don McCanne, MD

This Canadian study provides a great example of how we, in the United States, “think up” policies to control health spending while improving quality, and then apply those policies simply because they “should work.” Many of these policy decisions are used to divert our attention from much more effective measures such as a single payer national health program.

In this instance, the theory is that unplanned readmissions after a previous stay in the hospital are avoidable with appropriate in-hospital and post-discharge management. If the professionals and other personnel would do their jobs right, quality would improve and the costs of re-hospitalization would be avoided.

Although the Canadians, with their single payer system, evaluated readmissions from the perspective of improving quality, the emphasis in the United States, with its market medicine, has been on costs (e.g., refuse payment for re-admissions).

This study demonstrates that the reasons for readmission are very complex and highly variable and have very little relationship to either human or systems failure. Readmission rates should not be a major driver of policy.

Through this distraction, we’ve been fooled again. It’s not lousy health care professionals who are the source of our problems, it is the inhumane and outrageously expensive market-based health care financing and allocation system that is the problem. That’s what we need to fix. Then we could set aside issues of greed and concentrate on health care quality instead, like the Canadians are doing.

Incidence of potentially avoidable urgent readmissions and their relation to all-cause urgent readmissions

By Carl van Walraven MD MSc, Alison Jennings MA, Monica Taljaard PhD, Irfan Dhalla MD MSc, Shane English MD, Sunita Mulpuru MD, Saul Blecker MD, Alan J. Forster MD MSc
CMAJ (Canadian Medical Association), August 22, 2011

Urgent, unplanned hospital readmissions are increasingly being used to measure institutional or regional quality of care. The public reporting of readmissions and their use in considerations for funding suggest a belief that readmissions indicate the quality of care provided by particular institutions. However, urgent readmissions are an informative metric only if we know what proportion of them are avoidable. If they are rarely avoidable, they would be a poor gauge of the quality of patient care.

Current estimates of the proportion of urgent readmissions that are avoidable are unreliable. In a systematic review of 34 studies that reviewed how many readmissions were avoidable, 3 of the studies relied solely on combinations of administrative diagnostic codes, and most used undefined or subjective criteria. In addition, most of the studies were conducted at a single centre and used only one reviewer. The proportion of readmissions deemed avoidable varied widely, from 5.1%6 to 78.9%,7 which reflected in part the lack of standardized and reliable methods to identify avoidable readmissions.

We conducted a multicentre prospective cohort study to elicit judgments from multiple practising physicians who used standard implicit review methods to determine whether urgent re admissions were potentially avoidable. We analyzed these judgments using a latent class analysis. We also measured the proportion of readmissions deemed avoidable and compared hospital-specific proportions of all-cause and avoidable readmissions.

Conclusion

Urgent readmissions deemed potentially avoidable were relatively uncommon, comprising less than 20% of all urgent readmissions following hospital discharge. Hospital-specific proportions of patients who were readmitted were not related to proportions of those whose readmissions were deemed avoidable.

Given the variety of causes and circumstances of the potentially avoidable readmissions in our study, interventions to decrease the risk of readmission need to be multifactorial in nature and malleable to be appropriately tailored for each situation.

Our study has important implications for research into the quality of hospital care. First, determining whether urgent readmissions were avoidable is a subjective judgment that requires detailed patient data, multiple reviewers and an analysis that accounts for differing reviewer accuracy when collating judgments. Such judgments cannot be determined accurately on the basis of administrative data alone, given the infinite combinations of patient, hospital, treatment and post-discharge factors that can influence urgent readmissions. Second, we found no association between hospital-specific proportions of all-cause and avoidable readmissions. Therefore, urgent readmissions should be used with caution to gauge the quality of hospital care.

http://www.cmaj.ca/content/early/2011/08/22/cmaj.110400.full.pdf+html

This Canadian study provides a great example of how we, in the United States, “think up” policies to control health spending while improving quality, and then apply those policies simply because they “should work.” Many of these policy decisions are used to divert our attention from much more effective measures such as a single payer national health program.

In this instance, the theory is that unplanned readmissions after a previous stay in the hospital are avoidable with appropriate in-hospital and post-discharge management. If the professionals and other personnel would do their jobs right, quality would improve and the costs of re-hospitalization would be avoided.

Although the Canadians, with their single payer system, evaluated readmissions from the perspective of improving quality, the emphasis in the United States, with its market medicine, has been on costs (e.g., refuse payment for re-admissions).

This study demonstrates that the reasons for readmission are very complex and highly variable and have very little relationship to either human or systems failure. Readmission rates should not be a major driver of policy.

Through this distraction, we’ve been fooled again. It’s not lousy health care professionals who are the source of our problems, it is the inhumane and outrageously expensive market-based health care financing and allocation system that is the problem. That’s what we need to fix. Then we could set aside issues of greed and concentrate on health care quality instead, like the Canadians are doing.

March 5, 2006

“When you’re sick, you present your medicare card, not your credit card. New Democrats will not stand idly by. We will be fighting each and every day for our precious medicare system.”

Jack Layton
(July 18, 1950 – August 22, 2011)

http://www.vancouversun.com/health/Quotes+Jack+Layton+words/5289596/story.html

And..

Letter from Jack Layton, MP, Député Toronto – Danforth

Leader of the Official Opposition/Chef de l’Opposition officielle
Leader, New Democratic Party/Chef, Nouveau Parti démocratique
August 20, 2011
Toronto, Ontario

Dear Friends,

(excerpt)

To young Canadians:

All my life I have worked to make things better. Hope and optimism have defined my political career, and I continue to be hopeful and optimistic about Canada. Young people have been a great source of inspiration for me. I have met and talked with so many of you about your dreams, your frustrations, and your ideas for change. More and more, you are engaging in politics because you want to change things for the better. Many of you have placed your trust in our party. As my time in political life draws to a close I want to share with you my belief in your power to change this country and this world. There are great challenges before you, from the overwhelming nature of climate change to the unfairness of an economy that excludes so many from our collective wealth, and the changes necessary to build a more inclusive and generous Canada. I believe in you. Your energy, your vision, your passion for justice are exactly what this country needs today. You need to be at the heart of our economy, our political life, and our plans for the present and the future.

My friends, love is better than anger. Hope is better than fear. Optimism is better than despair. So let us be loving, hopeful and optimistic. And we’ll change the world.
 
All my very best,
 
Jack Layton

http://antemedius.com/files/Jack_Layton_s_lett_1310744a.pdf

March 5, 2006

“When you’re sick, you present your medicare card, not your credit card. New Democrats will not stand idly by. We will be fighting each and every day for our precious medicare system.”

Jack Layton
(July 18, 1950 – August 22, 2011)

http://www.vancouversun.com/health/Quotes+Jack+Layton+words/5289596/story.html

And..

Letter from Jack Layton, MP, Député Toronto – Danforth

Leader of the Official Opposition/Chef de l’Opposition officielle
Leader, New Democratic Party/Chef, Nouveau Parti démocratique
August 20, 2011
Toronto, Ontario

Dear Friends,

(excerpt)

To young Canadians:

All my life I have worked to make things better. Hope and optimism have defined my political career, and I continue to be hopeful and optimistic about Canada. Young people have been a great source of inspiration for me. I have met and talked with so many of you about your dreams, your frustrations, and your ideas for change. More and more, you are engaging in politics because you want to change things for the better. Many of you have placed your trust in our party. As my time in political life draws to a close I want to share with you my belief in your power to change this country and this world. There are great challenges before you, from the overwhelming nature of climate change to the unfairness of an economy that excludes so many from our collective wealth, and the changes necessary to build a more inclusive and generous Canada. I believe in you. Your energy, your vision, your passion for justice are exactly what this country needs today. You need to be at the heart of our economy, our political life, and our plans for the present and the future.

My friends, love is better than anger. Hope is better than fear. Optimism is better than despair. So let us be loving, hopeful and optimistic. And we’ll change the world.

All my very best,

Jack Layton

http://antemedius.com/files/Jack_Layton_s_lett_1310744a.pdf

National Business Group on Health
August 18, 2011

Medical Plan Costs

In 2012, 63% of employers will increase the employee percentage contribution to premium costs, and 39% will increase in-network deductibles.

Consumer-Directed Health Care

More employers will be offering a consumer-directed health plan (CDHP) in 2012 than in previous years, with 73% planning to offer at least one CDHP next year. In addition, 17% of employers have or will move to a full replacement CDHP design in 2012. The most common type of CDHP employers will offer next year is a high-deductible health plan (HDHP) with a health savings account (HSA) (75%).
 
The most common method employers use to load health accounts is by contributing a predetermined amount per participant, with 59% of employers with HSAs doing so, and 84% doing the same for health reimbursement accounts (HRA).

Pharmacy Benefits

To manage pharmacy benefits, most employers use prior authorization (76%). The next most popular techniques are:
• quantity limits (72%)
• step therapy (65%)
• three-tier design (59%)

Retiree Health

Fewer employers offer retiree benefits to current active employees, with 26% covering all current actives and 38% covering a portion of their actives. Very few employers offer retiree health benefits for new hires, with 12% offering coverage to pre-65 retirees and 7% offering post-65 supplemental coverage to new hires.
 
The top strategies being used to control retiree health care costs are capping company contributions (45%), increasing employee contributions (31%) and eliminating coverage for future retirees (28%).

http://capsules.kaiserhealthnews.org/wp-content/uploads/2011/08/2012-NBGH-Plan-Design-Survey-Report-Embargoed-Edition.pdf

And…

Survey: Employers shift rising health costs to their workers

By Sam Baker
The Hill, August 18, 2011

Businesses are shifting away from co-pays, wherein employees pay a fixed dollar amount for healthcare services and the plan picks up the rest. Instead, they’re charging workers a percentage of the total costs. That can help make consumers more aware of the total cost of the healthcare they use.

“We are clearly seeing a march toward a more aggressive consumerist system,” said Helen Darling, president of the National Business Group on Health.

Darling said Thursday that shifting from co-pays to coinsurance is “a more subtle way to increase what the consumer pays.” She predicted that eventually, only governments and unions will keep offering fixed co-pays.

http://thehill.com/blogs/healthwatch/health-insurance/177361-employers-shifting-healthcare-costs-to-workers

Comment: 

By Don McCanne, MD

Employers are reducing the transparency of the massive shift of health care costs to their employees by using many different methods that individually do not look too onerous, but cumulatively have a major impact.

Some of the methods of shifting more health care costs to their employees include greater premium contributions, greater use of large deductibles and consumer-directed health plans, greater restrictions on pharmacy benefits, and a sharp reduction or elimination of retiree health benefits. One of the more subtle but important methods is reducing the use of co-payments (a fixed dollar amount for a service or product) and instead using coinsurance (a percentage of the amount charged). The percentages are usually much larger than the co-payments would be.

Most of the businesses surveyed are very large corporations (83 percent have over 10,000 employees). Their corporate executives and their passive shareholders have done very well in the last few decades, being beneficiaries of the upward transfer of wealth in our society. Their employees have not done so well and have experienced greater difficulties in managing their personal finances.

Rising health care costs are a problem for all of us. They are now so great that we need progressive methods of financing health care. Yet shifting costs from the wealthy corporate plutocracy to the employees is a regressive form of financing.

Supposedly employers are still contributing a large share of the premium, but only nominally. Most economists agree that employees pay the employer component of the premium though forgone wage increases, and wages have certainly been flat. Again, this is regressive financing.

In crafting the Affordable Care Act, efforts were made to protect employer-sponsored plans so that they would still be the largest source of health care coverage. Is this wise?

Not only is the financing regressive, it leaves in place the administratively wasteful private health plans that intrude on health care by taking away certain benefits and taking away choices of health care providers. It leaves in place the fragmented financing model of private plans that has been incapable of slowing the rate of growth in costs to a level closer to those of other industrialized nations. Furthermore, it leaves health policy decisions in the hands of corporate executives who are beholden above all to their investors, whereas the employees are mere pawns to be used to create wealth for the investors. Why else would they be using so many means to shift more health care costs to the employees?

Every time I write one of these commentaries, I think that the logic of an improved Medicare for All would make it an imperative. Maybe the problem is that logic would lead to health care justice, and that seems to be unthinkable in the United States.

Large Employers’ 2012 Health Plan Design Changes

National Business Group on Health
August 18, 2011

Medical Plan Costs

In 2012, 63% of employers will increase the employee percentage contribution to premium costs, and 39% will increase in-network deductibles.

Consumer-Directed Health Care

More employers will be offering a consumer-directed health plan (CDHP) in 2012 than in previous years, with 73% planning to offer at least one CDHP next year. In addition, 17% of employers have or will move to a full replacement CDHP design in 2012. The most common type of CDHP employers will offer next year is a high-deductible health plan (HDHP) with a health savings account (HSA) (75%).

The most common method employers use to load health accounts is by contributing a predetermined amount per participant, with 59% of employers with HSAs doing so, and 84% doing the same for health reimbursement accounts (HRA).

Pharmacy Benefits

To manage pharmacy benefits, most employers use prior authorization (76%). The next most popular techniques are:
• quantity limits (72%)
• step therapy (65%)
• three-tier design (59%)

Retiree Health

Fewer employers offer retiree benefits to current active employees, with 26% covering all current actives and 38% covering a portion of their actives. Very few employers offer retiree health benefits for new hires, with 12% offering coverage to pre-65 retirees and 7% offering post-65 supplemental coverage to new hires.

The top strategies being used to control retiree health care costs are capping company contributions (45%), increasing employee contributions (31%) and eliminating coverage for future retirees (28%).

http://capsules.kaiserhealthnews.org/wp-content/uploads/2011/08/2012-NBGH-Plan-Design-Survey-Report-Embargoed-Edition.pdf

And…

Survey: Employers shift rising health costs to their workers

By Sam Baker
The Hill, August 18, 2011

Businesses are shifting away from co-pays, wherein employees pay a fixed dollar amount for healthcare services and the plan picks up the rest. Instead, they’re charging workers a percentage of the total costs. That can help make consumers more aware of the total cost of the healthcare they use.

“We are clearly seeing a march toward a more aggressive consumerist system,” said Helen Darling, president of the National Business Group on Health.

Darling said Thursday that shifting from co-pays to coinsurance is “a more subtle way to increase what the consumer pays.” She predicted that eventually, only governments and unions will keep offering fixed co-pays.

http://thehill.com/blogs/healthwatch/health-insurance/177361-employers-shifting-healthcare-costs-to-workers

Employers are reducing the transparency of the massive shift of health care costs to their employees by using many different methods that individually do not look too onerous, but cumulatively have a major impact.

Some of the methods of shifting more health care costs to their employees include greater premium contributions, greater use of large deductibles and consumer-directed health plans, greater restrictions on pharmacy benefits, and a sharp reduction or elimination of retiree health benefits. One of the more subtle but important methods is reducing the use of co-payments (a fixed dollar amount for a service or product) and instead using coinsurance (a percentage of the amount charged). The percentages are usually much larger than the co-payments would be.

Most of the businesses surveyed are very large corporations (83 percent have over 10,000 employees). Their corporate executives and their passive shareholders have done very well in the last few decades, being beneficiaries of the upward transfer of wealth in our society. Their employees have not done so well and have experienced greater difficulties in managing their personal finances.

Rising health care costs are a problem for all of us. They are now so great that we need progressive methods of financing health care. Yet shifting costs from the wealthy corporate plutocracy to the employees is a regressive form of financing.

Supposedly employers are still contributing a large share of the premium, but only nominally. Most economists agree that employees pay the employer component of the premium though forgone wage increases, and wages have certainly been flat. Again, this is regressive financing.

In crafting the Affordable Care Act, efforts were made to protect employer-sponsored plans so that they would still be the largest source of health care coverage. Is this wise?

Not only is the financing regressive, it leaves in place the administratively wasteful private health plans that intrude on health care by taking away certain benefits and taking away choices of health care providers. It leaves in place the fragmented financing model of private plans that has been incapable of slowing the rate of growth in costs to a level closer to those of other industrialized nations. Furthermore, it leaves health policy decisions in the hands of corporate executives who are beholden above all to their investors, whereas the employees are mere pawns to be used to create wealth for the investors. Why else would they be using so many means to shift more health care costs to the employees?

Every time I write one of these commentaries, I think that the logic of an improved Medicare for All would make it an imperative. Maybe the problem is that logic would lead to health care justice, and that seems to be unthinkable in the United States.